Healthcare Provider Details

I. General information

NPI: 1952474090
Provider Name (Legal Business Name): CHRISTOPHER COSTANZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2190 LYNN RD STE 380
THOUSAND OAKS CA
91360-8029
US

IV. Provider business mailing address

2190 LYNN RD STE 380
THOUSAND OAKS CA
91360-8029
US

V. Phone/Fax

Practice location:
  • Phone: 805-373-9919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG46454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: